THE EFFECTS OF ANTENATAL HEALTH EDUCATION ON POSTNATAL

THE EFFECTS OF ANTENATAL HEALTH EDUCATION ON POSTNATAL CARE AMONG HIV POSITIVE WOMEN IN FRANCISTOWN CITY, BOTSWANA

by

STEMBILE MATAMBO

submitted in accordance of the requirements

for the degree of

MASTER OF ARTS

in the subject

HEALTH STUDIES

at the

UNIVERSITY OF SOUTH AFRICA

SUPERVISOR: DR JM MATHIBE-NEKE

NOVEMBER 2014

Student number: 46843639

DECLARATION

I declare that THE EFFECT OF ANTENATAL HEALTH EDUCATION ON POSTNATAL CARE AMONG HIV POSITIVE WOMEN IN FRANCISTOWN CITY, BOTSWANA is my own work and that all the sources that I have used or quoted have

been indicated and acknowledged by means of complete references and that this work

has not been submitted before for any other degree at any other institution.

4 December 2014

STEMBILE MATAMBO DATE Full name

THE EFFECTS OF ANTENATAL HEALTH EDUCATION ON POSTNATAL CARE AMONG HIV POSITIVE WOMEN IN FRANCISTOWN CITY, BOTSWANA

STUDENT NUMBER: 46843639 STUDENT NAME: STEMBILE MATAMBO DEGREE: MASTER OF ARTS DEPARTMENT: HEALTH STUDIES SUPERVISOR: DR JM MATHIBE-NEKE

ABSTRACT The purpose of the study was to determine the effect of antenatal health education on

postnatal care (PNC) among Human Immunodeficiency Virus (HIV) positive women in

Francistown city, Botswana. This study followed a quantitative research paradigm. Data

was collected with the aid of a questionnaire from eligible women who consented in

writing to participate in the study.

Forty-five percent (45%) (n=45) HIV positive women came with babies for 6 weeks PNC

and 55% (n=55) brought 8 weeks old babies either for weighing or for the two months

immunisation from 28 April to 10 June 2014.

The responses regarding the source of health education received were as follows: 40%

lay counselors, 31% midwives, 15% doctors, 5% nurses without midwifery, 5% cadre

unknown, 2% both lay counselors and midwives, 1% by a health education assistant

and 1% was not health educated at all.

Conclusion: The study revealed that HIV positive pregnant women received health

education from different cadres of health and mostly by lay counselors. Literature

indicates that lay counselors may give health information but at a very superficial level.

Key concepts

Acquired Immune Deficiency Syndrome (AIDS); antenatal health education; effect; HIV

positive women; postnatal care (PNC).

ACKNOWLEDGEMENTS I wish to sincerely acknowledge the following: • God Almighty who gave me the strength and a renewed mind that drove me to

achieve my learning goals • My dear husband Charles who saw my academic potential and encouraged me

to study • My wonderful children Michael, Lina, Yvonne, Tawanda and my two

grandchildren who motivated me to be an example to them • My two spiritual daughters who helped with editing; Chamada Phuti and Phemelo

Masilo • My faculty advisors Dr MB Monyemore and Dr Mathibe-Neke who gave me

direction through my Master’s degree studies • My supervisors at work who paved a way through guiding me during work related

research and report writing • My two mentors, Mrs Unami Mathebula and Mr Blessing Mandizha who believed

that I would make it • My colleagues at work Chipo and Mmapula who were of great support during

data collection • Francistown district health management team for allowing me to undertake the

study in their district • The nurses in-charge of Lapologang and Masego clinic and their staff who

exhibited wonderful interpersonal relationships during the study • Finally the participants who were willing to share their experiences on health

education obtained during antenatal care • I dedicate this work to my late dad, Wallace and my mother Margaret who taught

us that the sky in learning is the limit

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Table of Contents CHAPTER 1 .................................................................................................................................. 1

OVERVIEW OF THE STUDY ....................................................................................................... 1

1.1 INTRODUCTION ........................................................................................................ 1

1.2 THE BACKGROUND OF THE STUDY ...................................................................... 1

1.3 STATEMENT OF THE RESEARCH PROBLEM ........................................................ 4

1.4 PURPOSE OF THE STUDY ....................................................................................... 4

1.5 RESEARCH QUESTIONS ......................................................................................... 5

1.6 OBJECTIVES OF THE STUDY .................................................................................. 5

1.7 DEFINITION OF CONCEPTS .................................................................................... 5

1.8 METHODOLOGY ....................................................................................................... 7

1.9 SIGNIFICANCE OF THE STUDY............................................................................... 8

1.10 SCOPE AND LIMITATION OF THE STUDY .............................................................. 8

1.12 CHAPTER DIVISION ................................................................................................. 8

1.13 CONCLUSION ........................................................................................................... 9

CHAPTER 2 ................................................................................................................................ 10

LITERATURE REVIEW .............................................................................................................. 10

2.1 INTRODUCTION ...................................................................................................... 10

2.2 LITERATURE SEARCH ........................................................................................... 10

2.3 INTERNATIONAL LITERATURE ON ANTENATAL AND POSTNATAL HEALTH EDUCATION ............................................................................................................ 11

2.4 LITERATURE REVIEW ON BOTSWANA ................................................................ 13

2.5 CONCLUSION ......................................................................................................... 13

CHAPTER 3 ................................................................................................................................ 14

METHODOLOGY ........................................................................................................................ 14

3.1 INTRODUCTION ...................................................................................................... 14

3.2 RESEARCH DESIGN ............................................................................................... 14

3.2.1 Research methods ................................................................................................... 14

3.2.2 Setting ...................................................................................................................... 15

3.2.3 Population and sample selection .............................................................................. 15

3.3 INCLUSION/EXCLUSION CRITERION ................................................................... 15

3.3.1 Sample frame ........................................................................................................... 16

3.3.2 Accessible population ............................................................................................... 16

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3.4 DATA COLLECTION ................................................................................................ 16

3.4.1 Pilot study ................................................................................................................. 17

3.4.2 Data collection process ............................................................................................ 17

3.4.2.1 Primary data ............................................................................................................. 17

3.4.2.2 Secondary data ........................................................................................................ 18

3.4.3 Validity and reliability ................................................................................................ 18

3.4.3.1 Internal validity ......................................................................................................... 19

3.4.3.2 External validity ........................................................................................................ 19

3.4.4 Reliability .................................................................................................................. 20

3.5 DATA ANALYSIS ..................................................................................................... 20

3.6 ETHICAL CONSIDERATIONS ................................................................................. 21

3.6.1 The respondents ...................................................................................................... 21

3.6.2 The institution ........................................................................................................... 22

3.6.3 Researcher ............................................................................................................... 23

3.6.4 Ethics pertinent to the topic ...................................................................................... 23

3.7 CONCLUSION ......................................................................................................... 23

CHAPTER 4 ................................................................................................................................ 24

DATA ANALYSIS AND INTERPRETATION OF FINDINGS ....................................................... 24

4.1 INTRODUCTION ...................................................................................................... 24

4.2 THE PURPOSE OF THE STUDY ............................................................................ 24

4.2.1 Objectives of the study ............................................................................................. 24

4.3 AN OVERVIEW OF RESULTS ................................................................................. 24

4.3.1 Biographical data ...................................................................................................... 25

4.3.1.1 Respondent’s age .................................................................................................... 25

4.3.1.2 Marital status ............................................................................................................ 26

4.3.1.3 Religion .................................................................................................................... 27

4.3.1.4 Accommodation ........................................................................................................ 29

4.3.1.5 Educational level ...................................................................................................... 29

4.3.1.6 Employment status ................................................................................................... 30

4.3.2 Number of pregnancies ............................................................................................ 31

4.3.3 Knowledge of HIV positive status ............................................................................. 31

4.3.4 Frequency distribution for the parity of women ......................................................... 32

4.3.5 Women given antenatal health education ................................................................ 33

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4.3.6 ANC health education in Botswana .......................................................................... 34

4.3.7 Hypothesis testing .................................................................................................... 37

4.4 CONCLUSION ......................................................................................................... 39

CHAPTER 5 ................................................................................................................................ 40

SUMMARY, CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS .............................. 40

5.1 INTRODUCTION ...................................................................................................... 40

5.2 PURPOSE AND AIM OF THE STUDY ..................................................................... 40

5.3 STUDY METHODS .................................................................................................. 41

5.4 CONCLUSION BASED ON THE STUDY OBJECTIVES ......................................... 41

5.5 BRIEF SUMMARY OF THE STUDY ........................................................................ 42

5.5.1 Conclusion ................................................................................................................ 43

5.6 LIMITATIONS OF THE STUDY ................................................................................ 43

5.7 RECOMMENDATIONS FOR PRACTICE ................................................................ 44

5.8 RECOMMENDATIONS FOR FURTHER RESEARCH ............................................ 44

5.9 CONCLUSION ......................................................................................................... 45

LIST OF REFERENCES ............................................................................................................. 46

iv

LIST OF TABLES

Table 4.1 Association of education level, accommodation and marital status ....................... 29 Table 4.2 Frequency distribution for the parity of women (N=100) ........................................ 33 Table 4.3 Questionnaire responses ....................................................................................... 35

v

LIST OF FIGURES

Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7

Respondents’ age (N=100) ............................................................................ Participants’ marital status (N=100) ............................................................... Participants’ religious background (N=100) ................................................... Employment status of HIV positive postnatal women in the study (N=100) .. Number of pregnancies and term babies born to women in the study period (Francistown, Botswana 2014) (N=100) ............................................. Knowledge of HIV positive women/period knowing HIV positive status (N=100) .......................................................................................................... Women given antenatal health education (N=100) ......................................

26 27 28 30 31 32 34

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ABBREVIATIONS AND ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care

DHMT District Health Management Team

DNA Deoxy Ribo Nucleic Acid

HAART Highly Active Antiretroviral

HIV Human Immunodeficiency Virus

HRDC Health Research and Development Division (Council)

PCR Polymerase Chain Reaction

PNC Postnatal Care

UNFPA United Nations Population Fund

UNISA University of South Africa

WHO World Health Organization

vii

LIST OF ANNEXURES

Annexure A UNISA Ethical clearance certificate Annexure B HRDC Botswana approved study permit Annexure C Francistown DHT permission to conduct study Annexure D Questionnaire Annexure E Informed consent form

1

CHAPTER 1

OVERVIEW OF THE STUDY 1.1 INTRODUCTION

Chapter 1 presents the background information which highlight the rationale for the

study, motivation for the study, statement of the research problem, purpose and

objectives of the study, definition of concepts, research question, an overview of the

research methodology, an outline of chapters, the significance of the study, the scope

and limitation of the study and the conclusion for the chapter.

1.2 THE BACKGROUND OF THE STUDY

Botswana has a population of 2 024 904 and Francistown, the second largest city in the

country, has a population of 100 079. The study was carried out in Francistown. Health

education is defined by the World Health Organization (WHO) as any combination of

learning experiences designed to help individuals and communities to improve their

health by increasing their knowledge or influencing their attitudes. This education is

given to individuals, families and communities (WHO 2013:1). Health education requires

participation of the target group for it to be sustained. Antenatal health education within

the context of this study, includes a combination of learning experiences offered to

pregnant women to increase their knowledge and equip them to make positive informed

decisions during antenatal period, throughout labour and delivery and during the

postnatal period. In most cases, according to the Botswana National Guidelines on

Prevention of Mother-to-Child-Transmission (Ministry of Health (Botswana) 2011:8). HIV

positive women are mostly diagnosed during the antenatal (ANC) period as all pregnant

women are offered HIV voluntary counseling and testing. Warren, Daly, Taure and

Mongi (2006:80) state that there is a greater risk for maternal mortality among HIV

positive women than HIV negative women. AIDS info (2012) states that women who are

HIV positive have additional health education needs that include, CD4 count, additional

education on antiretroviral therapy for mother and baby, HIV tests for the baby, referral

2

to support groups and stakeholders, feeding methods for the baby, general hygiene and

nutrition for the mother.

Postnatal care (PNC) means the care offered to the mother and baby six weeks

following childbirth in the maternity unit, primary health care setting or home based.

Postpartum care encompasses management of the mother, newborn and infant during

the postnatal period. “This period usually considered being the first few days after

delivery, but technically it includes the six-week period after childbirth up to the mother's

postpartum checkup with her health care provider”. It involves keeping delivered babies

for at least 24 hours, timely home visits from day 2 of delivery and attendance for PNC

at a health care facility at 6 weeks post-delivery (Jacobson 2002:2).

The health care workers besides rendering care already mentioned above provide

information which promotes vaccination and birth registration. During home visits, the

health care workers also collaborate with community health workers who could be

providing extended PNC at home. It is important therefore to establish functional referral

systems between home and the health care facilities. PNC extent to the provision of

health information to promote healthy behaviour and promote exclusive feeding

methods which could either be formula feeding or breastfeeding. The information

includes the importance of ensuring that the baby is kept in a warm environment. The

mother is provided with health information on diet, rest, sleep, supportive systems,

family planning, sex after delivery, identification of illnesses for example pneumonia in

the baby so that the baby can be treated timeously. The mother is also taught to identify

danger signs for her and her newborn baby. Postnatal health information re-enforces

the antenatal health education that was given during ANC.

Demographic and health surveys contacted between 1999 and 2004 have shown that

four in ten women who had live births in five years preceding the survey had not

received any postnatal care in the first two days of delivery. The UN Millennium Project

(2005) revealed that there is substantial evidence that prove that the use of maternal

care services is closely linked to economic status. Analysis of existing data in different

countries showed that the wealthy have more access to maternal health services than

the poor (Gwartkin et al 2005; Ronsman & Graham 2006; Stanton et al 2007). Fort et al

(2006) found out that one quarter of the women from the wealthiest households were

http://www.healthline.com/galecontent/childbirth-1

3

four times more likely to receive post-partum care than the poor. This is also relevantly

true of the findings of this study. The respondents were not wealthy but generally those

with high school education attended postnatal care.

A study by Bhartia and Cleveland (1995) showed that there is a positive connection

between higher education and postnatal attendance. It was proven in some studies that

women who have secondary education or higher are more independent to demand

services. Those who had primary education were more inclined to seek antenatal care

than postnatal services. In Characteristics of an effective health education curriculum by

The Centers for Disease Control and Prevention (2013b), it is stated that health

education must be goal oriented and have behavioural outcomes. This means that if

HIV positive women are effectively health educated during the antenatal period, they

must exhibit positive outcomes among them attending postnatal care clinics.

According to a research on Antenatal care: meeting consumer needs … undertaken by

Svensson (2005) in Sydney Australia, some of the participants questioned the skills and

facilitation of learning programs on antenatal and postnatal care that the health

educators had. The research recommended that it is vital for health care workers to be

trained and mentored. They concluded that effective and high quality antenatal

education that was facilitated by skilled trained educators could produce superior

postnatal outcomes.

According to Warren et al (2006:80), in Opportunities for Africa’s Newborns, an

estimated 1.16 million African babies die in the first 28 days of life and 850 000 do not

live to exceed the week they were born. 51% of all these deaths occur in the Sub-

Saharan region of which Botswana is one of them.

In Botswana, the Ministry of Health National guidelines on Prevention of Mother-to-Child

transmission of HIV states that 95% of women seek antenatal care where they are

health educated by Midwives, Lay Counselors, Medical doctors and other cadres.

Pregnant women are encouraged to attend antenatal care from fourteen weeks of

gestation (Ministry of Health (Botswana) 2011). According to The Ministry of Health

Botswana policy guidelines, all pregnant women are offered HIV testing during their first

visit to the clinic (Ministry of Health (Botswana) 2004:35). According to the Ministry of

4

Health (Botswana) (2007), those who are HIV positive receive the usual health

education plus health information related to their HIV positive status. The antenatal

education is supposed to prepare them for pregnancy, labour and delivery and postnatal

care.

This study showed the outcomes of postnatal care given the services and service

providers who render antenatal health education.

1.3 STATEMENT OF THE RESEARCH PROBLEM

In view of the risks facing HIV positive women during PNC, there is a need to determine

the effect of antenatal health education on PNC among HIV positive women. The risks

facing HIV positive women during the postnatal period include; poor wound healing due

to compromised immunity, cervical changes which can lead to cancer of the cervix and

haemorrhage due to HIV-related thrombocytopaenia (Warren et al 2006:80). The

mother may develop anaemia due to HIV-related illnesses, chronic diseases,

malnutrition and wasting. Hormonal contraceptives may cause drug-to-drug reactions

with anti-retroviral medications and intra uterine contraceptive devices may contribute to

infections. HIV positive women who choose to breastfeed face the risk of transmitting

the HIV virus to the baby if they are not taking anti-retroviral treatment or prophylaxis

(Warren et al 2006:81). This study was motivated by an average of 55% postnatal

attendance noted during clinic audits in Francistown health facilities from 2008-2012.

This finding implied that 45% of women who were HIV positive did not report for PNC.

This means that both the mothers and the babies were at risk of developing

complications and that babies were likely not to have had a PCR HIV test which is

necessary for early initiation of ARVs if the baby is HIV positive.

1.4 PURPOSE OF THE STUDY

The purpose of this study was to determine the effect of antenatal health education on

PNC among HIV positive women.

5

1.5 RESEARCH QUESTIONS

The research questions for this study were:

• What health information do HIV positive women receive during the antenatal

period?

• What effect does antenatal health education received by HIV positive pregnant

women have on PNC?

• What aspects of antenatal health education can be recommended to ensure

comprehensive health education for HIV positive pregnant women?

1.6 OBJECTIVES OF THE STUDY

This study aimed to

• describe the health education that HIV positive women who attended postnatal

clinics, received during the antenatal period

• determine the effect of the antenatal health education given to HIV positive

women

• recommend aspects to be included in the antenatal health education for HIV

positive women to ensure comprehensive health education

1.7 DEFINITION OF CONCEPTS

• Effect The Free Dictionary (2009:1) defines effect as something brought about by a result or

the power to produce an outcome, achieve a result or have an influence.

6

Operational definition

Effect in this study refers to an outcome or influence that health information given during

ANC have on postnatal attendance among HIV positive women.

• Antenatal health education

Health education is defined by WHO (2013:1) as any combination of learning

experiences designed to help Individuals and communities improve their health by

increasing their knowledge or influencing their attitudes.


Health information that is given during pregnancy to prepare women to make informed

decisions that have positive medical outcomes and result in optimum health for both

mother and the baby is referred to as antenatal health education in this study.

• Human Immunodeficiency Virus (HIV) HIV is infection with the Human Immunodeficiency Virus (HIV) which leads to

progressive destruction of the human immune system (Encyclopaedia of Global Health

2008). An HIV positive woman therefore is a woman who is infected by the HIV.

• HIV positive pregnant woman

A pregnant woman who is infected by the HIV virus (Encyclopaedia of Global Health 2008).

• Antenatal care The Bailliere’s Midwives Dictionary (2012) defines ANC as the bio-psycho-social care

provided during pregnancy by midwives and obstetricians to ensure satisfactory fetal

and maternal health, enable early detection and treatment of any deviation from normal.

The ANC period covers pregnancy to delivery i.e. conception to birth of the baby.

7


Pregnant women are examined to determine that both the mother and the baby are

healthy and to prepare for a safe delivery. Postnatal women are therefore assumed to

be knowledgeable since they would have received antenatal health education.

• Postnatal care The Dictionary of Medical Terms (2008) defines PNC as care given to a woman and her

baby after the birth of her child. The postnatal period covers the first six weeks of a

baby’s life.


In this study, the postnatal period is from birth to 6 weeks post-delivery. Women who

delivered are provided with services that ensure optimum health for them and their

babies during this period and onwards. These are women from which data were

collected by use of a researcher administered questionnaire.

1.8 METHODOLOGY

This study followed a quantitative research paradigm. Quantitative research is

concerned with measuring attributes and relationships in a population (Polit & Beck

2008:15, 729). In this regard, the effect of the antenatal health education and its

relationship with PNC among HIV positive women is described in chapter 3 which is

covering methodology. The research methods include population universum, inclusion/

exclusion criterion, the target population and the sample frame. The accessible

population sample is outlined including the sample size, sampling methods, samples

obtained per clinic during data gathering and design of questionnaires. Data analysis is

outlined in chapter 3.

8

1.9 SIGNIFICANCE OF THE STUDY

This research impacts on nursing practice in that it addresses a clinical concern and

generates results to significantly improve nursing practice through health education. The

health care human resource, the community and society at large will benefit from this

study. HIV positive women who access PNC services will have optimum health for

themselves and their babies. This will result in the reduction of maternal and child

morbidity and mortality rates in Botswana and eventually internationally.

1.10 SCOPE AND LIMITATION OF THE STUDY

The limitations that were experienced in the study were that during data collection, the

parity of the women confounded the knowledge that a woman coming to PNC with a

first baby had compared to one who had more than one baby. Women who had more

than one baby had more information than those who had a first pregnancy. This came

about because those with more than one baby had been offered health education

during previous pregnancies.

1.11 ETHICAL CONSIDERATIONS

Ethical clearance to conduct the study was obtained from the University of South Africa

and from the Health Research Committee (Annexure A). Participation in the study was

voluntary. Ethical aspects pertaining to the study will be discussed in detail in chapter 3.

1.12 CHAPTER DIVISION

The chapters following chapter 1, are chapter 2 (literature review), chapter 3 (research

methodology), chapter 4 (data analysis) and chapter 5 (results, limitations and

conclusions and recommendations).

9

1.13 CONCLUSION

In this chapter, the introduction, background information and the problem statement

have been outlined. The purpose and the objectives of the study were explained.

Research methods, analysis, results, scope and limitations, chapter division and the

significance of the study were outlined. The next chapter discusses literature review

related to the study.

10

CHAPTER 2

LITERATURE REVIEW 2.1 INTRODUCTION

Chapter 2 presents the literature review which is explained by Charmers as a process of

taking stock of existing knowledge in order to make informed choices about the focus of

the study (Joubert, Ehrlich, Katzenellenbogen & Abdool Karim 2007:66). The researcher

does not simply make summaries of reports but makes an in-depth study to evaluate

what has already been studied and the findings therefore. Literature review also helps

to identify any strengths and weaknesses of the present study. The literature review will

also help put the new results into context and help direct further studies related to this

topic.

2.2 LITERATURE SEARCH

Several searches were made on the study topic using the PubMed, Medline and the

Cochrane search engines. Eleven relevant topics were identified using the words

antenatal health education in HIV/AIDS in PubMed. Only one article titled, “Awareness

and attitude of antenatal clients towards HIV voluntary testing and counseling in Amim,

Keno Teaching Hospital, Kano, Nigeria” reported by Lliyasu, Kabir and Galadanci

(2005:7-32) was relevant to the current study. The majority of the participants had some

knowledge of HIV/AIDS. Six percent of the participants disapproved of voluntary

counseling and testing for HIV. The authors concluded that there is a need to intensify

health education to convince the minority six percent of the benefits of voluntary

counseling and testing for HIV.

The Medline search engine gave five reports on antenatal health education in general.

There were no reports specifically including information relevant to HIV positive women.

Only one Cochrane report, “Patient support and education for promoting adherence to

Highly Active Antiretroviral (HAART) for HIV/AIDS” was found. This report is from a

11

study that was published by Ruedo, Park, Wyllie, Bayoumi, Tynan, Antoniou, Rourke

and Glazer (2009:1).

2.3 INTERNATIONAL LITERATURE ON ANTENATAL AND POSTNATAL HEALTH EDUCATION

According to Warren et al (2006:80) in their book, Opportunities for Africa’s Newborns,

an estimated 1.16 million African babies die in the first 28 days of life and 850 000 do

not live to past the first week of life, and that 51% of all these deaths occur in sub-

Saharan Africa, a region of the world to which Botswana belongs. Researchers have

linked maternal mortality with economic development. The well-developed countries

have low maternal mortality rates compared to the poorer countries UNFPA (2007),

Population Resource Centre (2001) and Koblinsky, Timyan and Gay (1993:14) state

that forty percent of women who deliver annually develop complications. The

complications can include long-term disabilities, chronic pelvic pain, and damage to

reproductive organs, kidney failure, uterine rupture, infertility or mental disability. Death

in babies occurs due to low birth weight, infections and prematurity. Child disability and

poor child development originate from the early postnatal and childbirth period. Most of

the child deaths occur before the first month of life, a period that falls before the 6 week

visit, when PNC is sought in Botswana and many other countries. In most African

countries, mothers and babies are lost because the mothers do not attend postnatal

clinics or are not informed about the importance of PNC (Warren et al 2006:3).

Specific education, health policies, broad social and economic policies influence health

physically, mentally and socially. The Institute of Public Health in Ireland (2008:5)

states that at individual level, the knowledge, personal and social skills provided through

education better equip individuals to access and use information and services to

maintain and improve their own and their family’s health. The educational level of

parents influence child and family health, furthermore, maternal health education

influences child and family health. HIV positive mothers who received quality health

education therefore are bound to be seeking PNC for their own and child’s optimum

health. It is stated in the “characteristic of an effective health education curriculum” by

the Centers for Disease Control and Prevention (2013b:1) that health education must be

goal oriented and have behavioural outcomes. This literature states also that health

12

education should enhance positive health behaviours, correct misconceptions and

enforce self-efficacy, personal and social competences which result in the promotion of

health and positive decision making behaviours.

According to AIDS info (2012:2), HIV positive pregnant women need to be equipped

through health education for the challenges that they are likely to face during the

postnatal period. The importance of the baby having a Polymerase Chain Reaction

(PCR) test at six weeks should be explained during the antenatal period. The possible

outcomes of the medical examinations, tests, prophylaxis and treatment for HIV/AIDS

should therefore be outlined during the antenatal period.

The WHO developed a PNC model in 1998 recommending the 6-6-6-6 rule where the

mother and her newborn baby should be monitored and cared for within 6 hours of the

baby’s birth, 6 days, 6 weeks and 6 months after delivery. This care should be provided

both at home and in the health care facility.

Warren et al (2006:84-69) explain some of the roles of health care workers which

include besides care already mentioned, the provision of information which promotes

vaccination and birth registration. During home visits, the health care workers also

collaborate with community health workers who could be providing extended PNC at

home. It is important to establish functional referral systems between home and the

health care facilities.

In Welcome Baby Home (2006a-d), the articles discuss postnatal care and emphasize

the fact that postnatal care involves the provision of health messages to promote

healthy behaviours and promote exclusive feeding methods which could either be

formula feeding or breastfeeding. The messages include the importance of ensuring

that the baby is kept in a warm environment. The mother is provided with health

information on diet, rest, sleep, supportive systems, family planning, sex after delivery

and the identification of illnesses. The mother is also taught to identify danger signs for

her and her newborn baby.

13

2.4 LITERATURE REVIEW ON BOTSWANA

In Botswana, pregnant women are encouraged to register for ANC before 14 weeks of

gestation (Ministry of Health (Botswana) 2011:30). This allows for ANC which includes

health education to be initiated early. Francistown has 15 health care facilities that offer

antenatal and PNC. All pregnant women are offered HIV information and testing on the

first ANC visit and HIV positive women receive the usual health education and

additional education pertaining to their condition and relevant care. The Ministry of

Health National Guidelines on Prevention of Mother-To-Child Transmission of HIV

(Ministry of Health (Botswana) 2011:24) states that 95% of women seek ANC where

health education is given by the midwife, lay counselor, medical doctor and other health

care workers. HIV/AIDS management is a priority in Botswana.

2.5 CONCLUSION

Chapter 2 discussed and explained what literature review is, literature searches that

were conducted, the international literature that pertains to antenatal and postnatal

health education and literature review relating to antenatal and postnatal health

education in Botswana.

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CHAPTER 3

METHODOLOGY 3.1 INTRODUCTION Chapter 3 presents the research design, research methods, population universum,

inclusion/exclusion criterion, the target population and the sample frame. The

accessible population sample is outlined including the sample size, sampling methods,

samples obtained per clinic during data gathering and design of questionnaires.

This study followed a quantitative research paradigm because quantitative research is

concerned with measuring attributes and relationships in a population (Polit & Beck

2008:15; 729).

3.2 RESEARCH DESIGN

A quantitative design was chosen for this study, and a descriptive cohort quantitative

design was used. This was chosen as a suitable design because the purpose of the

study was to determine the effect of antenatal health education on PNC/ attendance

amongst HIV positive women as the aim of quantitative research is to classify features,

count them and then construct some statistical models that help in explaining the

researcher’s observations (Polit & Beck 2008:14-18). A descriptive study often takes the

form of a survey, as applicable to this study which is aimed at quantifying the effect of

antenatal health education on PNC/attendance among HIV positive women (Joubert et

al 2007:78). Joubert et al (2007:78) and Rodney (2007:188-189) state that surveys are

typically cross-sectional studies and are used to evaluate programmes that aim to

change health care behaviour.

3.2.1 Research methods

This section discusses the population and sample selection, data collection and data

analysis that were utilised in the study. The researcher initially selected the two busiest

15

clinics in Francistown with a work load of about 100-150 patients a day. Data was

collected every week day for three weeks after which the researcher only managed to

collect data on Mondays and Fridays due to work constraints.

3.2.2 Setting

Two of the 15 health care facilities in Francistown, Botswana namely Masego and

Lapologang clinics were used for data collection. The majority of the sexual

reproductive clients seek services at either Masego or Lapologang clinics. After

obtaining permission to carry out the study from the Ministry of Health and the District

Health Management Team, the researcher was offered a consulting room in each of the

two clinics to use for data collection.

3.2.3 Population and sample selection

• Population universum

Any HIV positive woman within the child bearing age (15-49 years) and who had

attained majority age of 21 years and attended any of the two clinics in Francistown out

of the 15 health care facilities were offered an opportunity to participate in the study if

they gave consent to do so. Convenient sampling was used i.e. any eligible HIV positive

postnatal woman with a baby who was six to eight weeks old were offered an

opportunity to participate in the study. Women were coming for six weeks PNC whilst

the eight weeks postnatal women brought their babies for weighing, collection of infant

formula which is offered by the government or for the first vaccination of the baby.

3.3 INCLUSION/EXCLUSION CRITERION

Batswana and non-citizen HIV positive postnatal women who are 21 to 49 years who

consented to participate were included in the study. Twenty-one years is the age of

majority in Botswana. Twenty-one to forty nine years include the child bearing age.

Teenagers i.e. thirteen to twenty year-old pregnant women were excluded because their

parents would need to sign consent forms for them this would have posed a challenge

because most of the young people live in town while their parents live in the villages.

16

HIV positive women within 6 to 8 weeks postnatal period who attend any two of the 15

health care facilities in Francistown and are less than 21 years or older than 49 years of

age were excluded from this study. Any woman who did not consent to participate was

also excluded from this study.

A total of 100 HIV positive 6-8 weeks postnatal mothers attending 2 of the 15 health

care facilities in Francistown city were sampled. A sample size less than 100 would

have brought out results that may not be easy to generalise to the population using a

95% confidence interval. The number of HIV positive antenatal pregnant women in

Francistown ranges between 1 000 and 1 350 per annum.

3.3.1 Sample frame

All women within 6 to 8 weeks postnatal period who were HIV positive who attended

any two of the 15 health care facilities selected for the study in Francistown during the

study period were offered an opportunity to participate. All selected participants had a

questionnaire administered. None of the women who offered to participate declined.

3.3.2 Accessible population

All HIV positive postnatal women who were within the ages of 21 to 49 years attending

any two of the 15 health care facilities in Francistown were offered the opportunity to

participate in the study if they were eligible. This reduced any selection bias that would

affect generalisation of the findings.

3.4 DATA COLLECTION

Polit and Hungler (1995:639) define data collection as “the gathering of information

needed to address a research problem”. Data collection started on 26 April and ended

on 30 June 2014. A total of 159 HIV positive women were expected to have attended 6

weeks PNC and brought their children for the first immunisation at 8 weeks of birth.

Only 45 women managed to attend and some of these came from surrounding clinics.

Some of the reasons for this low attendance for PNC will be explained under the

discussion section. The administration of the questionnaire at the clinics was conducted

17

by the UNISA student researcher who is a qualified general nurse, midwife with a

certificate in adult education, degree in Health Care Management and a postgraduate

diploma in Public Health.

Data was collected from eligible women who consented in writing to participate in the

study. According to Polit and Hungler (1995:33), the approaches used in quantitative

studies are more structured and use a formal instrument that is used to collect exactly

the same information from all participants.

3.4.1 Pilot study

A pilot study was carried out on 10 respondents using the questionnaires in two of the

clinics before embarking on the main study project. The researcher excluded the clinic

name and date of data collection to maintain anonymity. These were added to the

questionnaires before embarking on the main study. The Setswana version of the

questionnaire had some spelling mistakes which were also corrected before

commencing data collection for the main study. Most of the respondents chose to

respond to Setswana questionnaires as opposed to the English questionnaire. The pilot

study was carried out in a private and well ventilated consulting room within the clinic.

The questionnaire was reported by all respondents to be clear and easy to understand.

The respondents from the pilot study were included in the 100 cohort.

3.4.2 Data collection process

3.4.2.1 Primary data

A questionnaire was administered with each and every woman who gave consent to

participate in this study. According to Polit and Hungler (1995:188), questionnaires need

to be clearly written with questions that are simple and not ambiguous One advantage

of using questionnaires is that they can be applied to many populations as they are

flexible.

Each period of administering the questionnaire was scheduled to take 15-20 minutes

although some questionnaires were answered in 7-10 minutes. The questionnaire had

questions covering information on the respondent’s biographical data, antenatal health

18

education, postnatal information and care and health provider information. Codes were

allocated to the study respondents. No name was reflected on the data collection form

for the sake of confidentiality and to maintain anonymity. All data was captured

electronically.

Verbal responses were recorded in a uniform way on the questionnaire form.

Responses were quantified and analysed for interpretation and summaries including

percentages, other measurement of variables and measures of construct were made.

The data was stored under lock and key.

3.4.2.2 Secondary data

The researcher reviewed the postnatal registers in the two clinics where the study was

undertaken. This was useful in determining the effects of antenatal health education on

postnatal care among HIV positive pregnant women. The assumption is that postnatal

visits would be proxy for receiving postnatal care.

3.4.3 Validity and reliability

Validity is the degree to which an instrument measures what it is intended to measure

(Polit & Beck 2008:735). According to Krueger, Nelson and Wolanin (1978:207), validity

is the maximisation of the true score variation and the minimisation of error variation of

the instrument. Joubert et al (2007:120) state ways of improving and evaluating validity

utilizing face, content, predictive and inconsistent validity. Face validity refers to the

measure that the question makes sense to those who are knowledgeable of the subject

and interviewers who are conversant of the language and culture of the participants. It is

important to ascertain that questions asked are representative of what is being

measured. In content validity, the measure should account for all elements or concepts

being investigated. Criterion validity refers to evaluating the measurement instrument

against the most valid measurements that are available. Predictive validity, in turn,

confirms a hypothetical association that was theoretically implied. Finally, inconsistent

validity refers to the fact that the measure may be valid in one group but will not be valid

in another group (Joubert et al 2007:120).

19

Polit and Hungler (1995:365) state that in construct validity, the question that is asked is

“Is the abstract concept being investigated adequately being measured by this

instrument?”

People who are conversant with midwifery such as my faculty advisor, my supervisor at

work, two midwifery lecturers and my work colleagues read the questionnaire draft and

contributed towards amendments that were included to come up with the final

questionnaire.

3.4.3.1 Internal validity

The questionnaire that was used for data collection was similar for all study

respondents. It included questions related to respondent’s biographical data, setting for

health education during the antenatal period and health education offered during the

antenatal period and then postnatal attendance from birth to 6-8 weeks after delivery.

Colleagues who are researchers, doctors, nurses and midwives were given an

opportunity to review the questionnaire. Experts such as senior researchers and

statisticians were consulted to review the tool before it could be used. The questionnaire

was piloted on 10 HIV positive postnatal women (6-8 weeks post-delivery) in the two

study sites. The researcher administered the questionnaire on women who volunteered

to be included in the pilot study to attain a quality tool that is stable before embarking on

the main study.

3.4.3.2 External validity

All HIV positive women who are 6 to 8 weeks postnatal who attended either Masego or

Lapologang clinics in Francistown city during the period of the study were offered an

opportunity to participate if they consented to do so. Convenient sampling was used to

identify eligible participants. The study did not discriminate anyone due to status, tribe

etc. The student researcher who is a qualified nurse midwife collected data by

administering the questionnaire to all respondents. This means that there was no

variation of experiences on the researchers collecting data. The results of the study

from the two clinics were generalised to the antenatal HIV positive mothers attending

clinics in Francistown city. Recommendations made in Chapter 5 will be applied in all of

20

the fifteen clinics in Francistown city. The information will also be disseminated to the

District Health Management Team and their staff, the Ministry of Health in Botswana

and other relevant stakeholders. The study findings will also be disseminated in

workshops in Botswana and in international conferences so that it can be generalised in

different countries.

3.4.4 Reliability

Reliability is the ability of an instrument to be repeatedly or constantly used and yield

the same results for the attribute it is supposed to measure. Reliability deals with

accuracy and consistency (Polit & Hungler 1995:347). The questionnaire was piloted on

10 respondents who volunteered to be included in two health care facilities in

Francistown which are Masego and Lapologang clinics. Questionnaires that have been

translated to Setswana (for non-English speaking HIV positive postnatal women) by

health care workers and approved by the HRDC in the Ministry of Health in Botswana

were administered. The PNC and attendance among HIV positive postnatal women was

correlated to the health information which is in the data collection tool to identify any

relationships.

3.5 DATA ANALYSIS

Research questions were analysed as follows:

• Biographical data that included the age of the respondents, their marital status,

the church which they attend, their educational qualifications, where they live, the

number of children they have and their employment status.

• The clinical information of the respondents which included the knowledge of the

period of the respondent’s HIV status and who gave antenatal health education

during their pregnancy.

• The health education that was actually given when the respondent was pregnant

and when the respondent received postnatal care.

Graphs and tables were used to classify and quantify data for clear interpretation.

21

3.6 ETHICAL CONSIDERATIONS

The Belmont report explains and summarises ethical principles which were identified by

the US National Commission for the protection of Human Subjects in biomedical and

behavioural research. Joubert et al (2007:31-32). The three basic principles included in

the report were; respect for persons, beneficence and justice.

Respect of people entails two ethical areas which are that individuals should be treated

as autonomous agents who are able to make deliberations of their choice and that

those who have diminished autonomy such as children, comatose persons etc. are to

be protected (Joubert et al 2007:32).

Beneficence and non-maleficence cover two convictions which are; (a) treating people

with respect, (b) respecting their decisions and (c) protecting them from harm and

making sure that their well-being is maintained. According to Joubert et al (2007:32-33),

it is important to maximise the possible benefits and minimise possible harm.

Justice deals with treating all participants alike and equitably. This does not mean that

people are equal but that they should receive the same treatment without prejudice.

3.6.1 The respondents

According to Burns and Grove (1999:80), the subject rights and rights of others must be

protected. This study did not infringe upon the rights of the subjects. Each and every

HIV positive postnatal woman who attended any of the 15 health facilities in

Francistown was given an equal opportunity to participate in the study as long as they

were above 21 to 49 years old. Those who were eligible and accepted to participate in

the study were given unique identification numbers for anonymity. No names were

used. Written consent was obtained from each and every respondent who accepted to

be involved in the study and that there was a questionnaire to be administered. The

administration of the questionnaire was 15-20 minutes only. Every participant was

respected and no harm was incurred. The risks and benefits of participating in the study

were outlined. There were no known risks anticipated except that the respondents may

spend more time than the time stated (15-20 minutes) and that a respondent may recall

22

past events and be upset. If this happens, the respondent was to be given time to reflect

and talk more about how she feels. She would also be referred to a health care worker

in the clinic who would help counsel her.

Respondents were given information on the advantages of being involved in the study.

This study had the advantage that participants received re-enforcement health

education during the administration of the questionnaire to equip them to make informed

health decisions. The participants were also referred to health care workers in the

health care facility for any treatment, referral or counseling.

HIV infected clients are prone to stigmatisation. To motivate the client to open up and

give information, privacy was maintained. Confidentiality was assured during the

administration of the questionnaire and with storage of the completed data collection

tools. All questionnaires are to be destroyed by shredding and deleting electronic data

after three years of completing the study.

Participation was voluntary. There was no treatment or procedure that was denied the

respondents because of being a study participant. Respondents were free to decide to

stop the administration of the questionnaire at any time they wished to do so.

Medication or health care services were to be rendered to participants even if a

participant decided to discontinue the study.

3.6.2 The institution

Ethical approval was sought from the Health Research and Development Division

(Council) of the Ministry of Health in Botswana (HRDC) (Annexure B). Letters for access

into clinics were obtained from the District Health Management Team in Francistown

city (DHMT) (Annexure C). The researcher obtained ethical clearance allowing her to

proceed with the research from the University of South Africa ethics committee

(Annexure A).

23

3.6.3 Researcher

The researcher provided all prospective respondents with information on what the

research was all about. The advantages and disadvantages of the research and the

risks and benefits of the research were explained. The questionnaire and the consent

forms were in English and Setswana to allow the respondents to choose the language

they were comfortable with. The researcher gave respondents an opportunity to consent

or not to consent to participate (Annexure E). She also gave contact details of other

people locally or in the Ministry of Health that the respondents could communicate with

if they needed to know more about the research or if they had further questions. The

researcher was honest and she acknowledged all sources of information.

3.6.4 Ethics pertinent to the topic

This study involved respondents who were vulnerable to stigmatisation and

discrimination. All respondents were treated equitably. Their decisions were respected.

No respondent needed any psychological assistance during the administration of the

questionnaire. All data was treated with utmost confidentiality. Data was stored

electronically in a password protected laptop and paper documents were kept in a

lockable cupboard. Data will be destroyed by shredding and electronic data will be

deleted after three years of the study. 3.7 CONCLUSION

Chapter 3 presented methodology of the study. This chapter discussed the research

design, research methods which included the setting, population and sample selection

and the inclusion and exclusion criterion. The sample frame, accessible population, data

collection process were outlined. The chapter also presented validity, reliability and

ethical consideration.

24

CHAPTER 4

DATA ANALYSIS AND INTERPRETATION OF FINDINGS 4.1 INTRODUCTION

Analysis, according to Polit and Hungler (1995:635), is a way of organising data in such

a way that research questions can be answered. This chapter focuses on the analysis,

interpretation and discussion of the results of this study. An Excel spread sheet was

used for exploration and analysis of data.

4.2 THE PURPOSE OF THE STUDY

The purpose of this study was to determine the effects of antenatal health education on


4.2.1 Objectives of the study

The objectives of this study were to:

• describe the health education that HIV positive women who attend postnatal

clinics received during the antenatal period

• determine the effects of the antenatal health education given to HIV positive

women



4.3 AN OVERVIEW OF RESULTS

Masego and Lapologang the two busiest clinics in Francistown were used for data

collection. A total number of 100 respondents sixty-one (n=61) were from Lapologang

clinic while thirty-nine (n=39) were from Masego clinic. The antenatal registers had a

total of 159 HIV positive women, who were supposed to attend 6 weeks postnatal care

25

within the period of data collection. A total of (n=91) out of the (n=159) HIV positive

women were to attend postnatal care at Lapologang and (n=68) at Masego clinic within

the data collection period. Forty-five percent (n=45) i.e. 27 from Lapologang plus 18

from Masego of the HIV positive women who came for 6 weeks postnatal care were

enrolled by the student researcher. The remaining fifty-five percent brought 8 weeks old

babies either for weighing or for the two months immunisation.

The variables that were under study included the biographical data of the respondent

where the age, marital status, level of education and housing were reviewed. The

respondents were asked about the duration that they have known that they are HIV

positive. Information on antenatal health education, the cadre who provided the health

information, postnatal home visits and clinic visits were documented.

Privacy was maintained during data collection to encourage respondents to open up

and give information. The researcher used a private consulting room normally used for

consultation by doctors and nurses to prevent stigmatisation.

4.3.1 Biographical data

A total of 100 HIV positive postnatal women with babies 6-8 weeks were included in the

study. Below are the biographical data results.

4.3.1.1 Respondent’s age Women with ages ranging from 21 to 49 years were included in the study. These

women had either come to the clinic for 6 weeks PNC, brought the baby for weighing at

8 weeks or for the first 8 weeks immunisation. Thirty percent of the women were within

the 31-35 year range, 22% were aged 26-30 years, 21% were in the 21-25 year bracket,

21% in the 36-40 years range and only 5% ranged between 41-49 years. Figure 4.1

shows a graphical presentation of the ages of women who participated in the study.

26

Figure 4.1 Respondents’ age (N=100) 4.3.1.2 Marital status

The highest percentage (82%) was single women followed by 15% being married

women, 2% were divorced and 1% comprised of widows.

0

5

10

15

20

25

30

21-25 yrs 26-30 yrs 31-35 yrs 36-40 yrs 41-49 yrs

Number and ages of HIV+ women attending Postnatal care ,child welfare and baby immunization in Masego and Lapologang clinics

in Francistown, Botswana(April to June 2014)

27

Figure 4.2 Respondents’ marital status (N=100)

4.3.1.3 Religion

Botswana is a Christian country with many denominations. Twenty-nine churches were

represented. Religion does not hinder women to seek modern health care services in

Botswana. Figure 4.3 illustrates the religious affiliation of the respondents.

82%

15%

2% 1%

single

married

divorced

widow

28

Figure 4.3 Respondents’ religion (N=100)

1 2 3 1

3 1 1 1

4 1

1 1 2

1 1 1 2

20

3

1 2

2

1

4

1

1

5

8 3

St Paul

12 Apostle

Adventists

Botswana New Apostle

Catholic

Disciples of Light

Dutch Reformed Church

Eleven Apostle

Eloi

Gospel of God churchInternational

Head Mountain

Healing church

Johane Masowe

Katloki

Messiah

Methodist

Old Apostle

29

4.3.1.4 Accommodation

Sixty-one percent of the respondents stay in rented housing, thirty seven percent own

their homes, one percent live in Government housing for staff and one percent live in

company houses. Housing helps in identification of social class. Researchers have

linked maternal mortality with economic development. The well-developed countries

have low maternal mortality rates compared to the poorer countries (UNFPA 2007;

Population Resource Centre 2001; Koblinsky et al 1993).

4.3.1.5 Educational level

Among the respondents, 77% (n=77) had completed high school, 12% (n=12)

completed primary school, 9% (n= 9) had a University degree and 2% (n=2) never went

to school. A study that was carried out by Bhatia and Cleveland in 1995 showed that

there is a positive connection between education and postnatal attendance. It was

proven in some studies that women who have secondary education or higher are more

independent to demand services. On the other hand, Bhatia and Cleveland (1995) state

that women who have primary education are more inclined not to seek antenatal and

PNC. This was very characteristic in this study as the majority of the respondents had

attained higher education and above.

Table 4.1 Association of educational level, accommodation and marital status

Educational level Number Percentage Accommodation Marital status

Rented Own Single Married Widow University 9 9 7 2 5 3 1 High school 77 77 50 27 68 9 0 Primary school

12 12 6 6 11 1 0

No education 2 2 1 1 1 1 0

The majority of women in the study was single and lived in rented houses despite their

educational qualification. Specific education, health policies, broad social and economic

policies influence health physically, mentally and socially. The Institute of Public Health

in Ireland (2008:5) states that at individual level, the knowledge, personal and social

skills provided through education better equip individuals to access and use information

30

and services in order to maintain and improve their own and their family’s health.

Educational level and level of parents influence child and family health. Maternal health

education influences child and family health. HIV positive mothers who received quality

health education therefore are bound to be seeking PNC for their own and child’s

optimum health. Seventy percent of the HIV positive women with babies 6-8 weeks had

attained high school.

4.3.1.6 Employment status Though the majority of these women were unemployed, they had attained high school

education. Gill, Pande and Malhotra (2007:21) state that high rates of female education

are consistently associated with an increase in the use of maternal health services.

They allude to the fact that women who are gainfully employed have more opportunities

to reduce maternal mortality. However, in this study 62% (n=62) of the women were

unemployed, they had attained higher education which enhanced them to seek health

care services.

Figure 4.4 Employment status of women in the study (N=100)

24%

6%

6% 62%

2%

Full employed

part-time employee

Self employed

unemployed

University students

31

4.3.2 Number of pregnancies

The respondents in this study were varied from gravida 1 to 9. 6% (n=6) were gravida 1,

28% (n=28) gravida 2, 33% (n=33) gravida 3, 11% (n=11) gravida 4, 11% (n=11)

gravida 5, 8% (n=8) gravid 6, 1% (n=1) gravida 7, 1% (n=1) gravida 8, 1% (n=1) gravida

9. The women also had varied parity (number of viable babies born) which is reflected in

figure 4.5 and in the frequency distribution table 4.2.

Figure 4.5 Number of pregnancies and term babies born to respondents (N=100)

4.3.3 Knowledge of HIV positive status All respondents were aware of their HIV positive status. Twenty-five (25%) knew that

they were HIV positive for 1 year, 33% (n=33) for 2-5 years and 42% (n=42) for more

than five years. The women were very comfortable to talk about their status and the

health education that they were given during pregnancy.

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9

Num

ber o

f via

ble

babi

es b

orn

(par

ity

Number of pregnancies (gravida)

Parity

Gravida

32

Figure 4.6 Number of HIV positive women/period knowing

HIV positive status (N=100)

4.3.4 Frequency distribution for the parity of women

Six women in the study had born the following viable babies:

n=6 had 1 baby born

n=33 had 2 viable babies at birth

n=30 3 viable babies

n=12 4 babies

n=12 5 viable babies

n=4 6 viable babies

n=2 7 viable babies

n=1 8 viable babies

The majority of women had 2-3 babies. This means that they most probably were

exposed to antenatal health education before. Mothers who have previously had babies

tend to have more knowledge from previous health education experience. The next

table shows that generally health education was given but the quality could not be

0

5

10

15

20

25

30

35

40

45

1 year 2-5 years 5+ years

number of HIV positive women/period knowing HIV positivestatus

33

determined in this study. It has already been proven that more than 50% of the

postnatal women did not attend the clinic where they had ANC.

Table 4.2 Frequency distribution for the parity of women (N=100) Parity Number Percentage 1 6 6 2 33 33 3 30 30 4 12 12 5 12 12 6 4 4 7 2 2 8 1 1

4.3.5 Women given antenatal health education According to AIDS info (2012:2), HIV positive pregnant women need to be equipped

through health education for the challenges that they are likely to face during the

postnatal period. The importance of the baby having a DNA/PCR test at six weeks

should be explained during the antenatal period. The possible outcomes of the medical

examinations, tests, prophylaxis and treatment for HIV/AIDS should be outlined during

the antenatal period.

In this study, 40% of the HIV positive women received health education from lay

counselors, 31% from midwives, 15% from doctors, 5% from nurses without midwifery,

5% did not know the cadre who gave them health education, 2% were given health

education by both lay counselors and midwives, 1% by a health education assistant and

1% did not receive health education.

34

Figure 4.7 Women given antenatal health education (N=100)

All the different cadres who gave health education have varied qualifications. This

affects the quality of health education that was offered. In characteristic of an effective

health education curriculum by the Centers for Disease Control and Prevention

(2013b:1), it states that health education must be goal oriented and have behavioural

outcomes. The researcher enrolled n=45 (28%) out of n=159 HIV positive postnatal

women with babies who were 6 weeks old. Several HIV positive postnatal mothers

brought babies who were three months and above for the first time to the clinic because

in Setswana culture, a woman has to stay in confinement for at least three months after

delivery (Botsetse). These women were excluded because their babies were older than

the 8 weeks cut off point.

4.3.6 ANC health education in Botswana According to the Botswana National Guidelines, pregnant women in Botswana are

encouraged to register for ANC before 14 weeks of gestation (Ministry of Health

(Botswana) 2011:30). This allows for ANC which includes health education to be

initiated early. Francistown has 15 health care facilities that offer antenatal and PNC. All

pregnant women are offered HIV information and testing on the first ANC visit, and HIV

0

5

10

15

20

25

30

35

40

45

Doctors Midwives Midwife/LayCounselor

Nursewithout

midwifery

HealthEducationAssistant

LayCounselor

Does notknow cadre

None

35

positive women receive the usual health education plus education pertaining to their

condition and relevant care.

Table 4.3 Health education content received by women

Questions Yes No Growth and development of the baby?

69% 30%

Diet appropriate for a pregnant woman

75% 25%

Importance of personal hygiene

84% 16%

Smoking during pregnancy 78% 28% Drinking alcohol or using other illicit drugs

74% 26%

Sexual intercourse in pregnancy

78% 22%

Vaccination for both mother and baby

79% 21%

Infections during pregnancy 73% 27% Bleeding during pregnancy 71% 21% HIV in pregnancy 93% 7% Information on Mother to Child transmission of HIV

90% 10%

Diabetes Mellitus in pregnancy

54% 46%

Taking medication in pregnancy

85% 15%

Vitamins and supplements for pregnant women

75% 25%

Delivery options 70% 30% Environmental and workplace exposure if applicable

38% 62%

Hereditary diseases 77% 23% Natural diseases 21% 79% Available medical, psychological and social services for HIV positive pregnant women

61% 39%

Infant feeding options 81% 19% Importance of attending PNC 70% 30% Blood tests necessary for mother after delivery

74% 26%

Six weeks HIV testing for your baby

87% 13%

Importance of taking ARV treatment

44% 56%

You visited the clinic or had a health care worker visit you at home

46% 54%

You visited the clinic at 6 weeks?

94% 6%

36

Table 4.3 indicates that health education was given during the antenatal period to 98%

of the respondents. The question, however, is how much of the health education was

given and at what depth? The cadres who provided health education to these women

had varied qualifications and experience.

The Population Resource Centre (2001) and Koblinsky et al (1993:12) state that 40% of

women who deliver annually develop complications. The complications can include long

term disabilities, chronic pelvic pain, and damage to reproductive organs, kidney failure,

uterine rupture, infertility or mental disability. Death in babies occurs due to low birth

weight, infections and prematurity. Child disability and poor child development originate

from the early postnatal and childbirth period. Lay counselors are not prepared in-depth

for them to give comprehensive health education in midwifery care.

The study also showed that 46% of the respondents were not visited at home until the 6

weeks postnatal visit. According to Population Resource Centre (2001) and Koblinsky et

al (1993:12), most of the child deaths occur before the first month of life, a period that

falls before the 6 week visit, when PNC is sought in Botswana.

WHO developed a PNC model in 1998 recommending the 6-6-6-6 rule where mother

and her newborn baby should be monitored and cared for within 6 hours of the baby’s

birth, 6 days, 6 weeks and 6 months after delivery. This care should be provided both at

home and in the health care facility. Warren (2006:80) states that half of postnatal

maternal deaths occur within the first week of baby’s delivery. This study revealed that

only 46% of the women were visited at home before they came to attend the 6 weeks

PNC.

The health care workers also provide information which promotes vaccination and birth

registration. During home visits, the health care workers also collaborate with

community health workers who provide extended PNC at home. It is important to

establish functional referral systems between home and the health care facilities.

37

4.3.7 Hypothesis testing

Given that the proportion of those that receive PNC in the population is equal to 55%.

Sample Total sample size = 100

Number of those that received PNC = 45

and ‘p = 0.45

‘q = 0.55

Zcalculated= p−po𝑆𝐷

SD = �pq𝑛

= �0.45 (0.55)100

= 0.04975

Our hypothesis is:

H0 : p = 0.55

HA : p ≠ 0.55

Now, Zcalculated= p− po𝑆𝐷

=0.45−0.550.4975

= 0.201

38

This is a two tailed test (i) At 5% level of significance

-1.96 1.96

Source: Researcher

We thus reject the null hypothesis if:

Zcalc> 1.96 or Zcalc<- 1.96

In this research the Z calc is 2.01. Therefore we reject the null hypothesis (H0) at 1%

level of significance. We thus conclude that the results are statistically significant at

1% level of significance.

(ii) At 1% level of significance

-2.576 2.576

Source: Researcher

39

We thus reject the null hypothesis if:

Zcalc>2.576 or

Zcalc< - 2.576

In this research the Z calc is 2.01. Therefore we accept the null hypothesis (H0) at 1%

level of significance. We thus conclude that the results are not statistically significant at 1% level of significance.

4.4 CONCLUSION

This chapter focused on analysis, interpretation and discussion of the results of this

study. The last chapter presents the summary, conclusions, limitations and recommen-

dations.

40

CHAPTER 5

SUMMARY, CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS

5.1 INTRODUCTION

This chapter concludes the study. The researcher summarised the findings; briefly

discusses the conclusion, limitations and recommendations for practice and further

studies.

5.2 PURPOSE AND AIM OF THE STUDY

The purpose of the study was to determine the effect of antenatal health education on


The study aimed to:

• describe the health education that HIV positive women who attend postnatal

clinics received during the antenatal period

• determine the effects of the antenatal health education given to HIV positive

women



The research questions were:

• What effect does antenatal health education have on HIV positive women on

postnatal attendance?

• What is the quality of antenatal health education given to HIV positive women?

• What strategies can be recommended to improve quality of antenatal health

education for HIV positive women?

41

5.3 STUDY METHODS

The study on the effect of antenatal health education on PNC among HIV positive

women in Francistown, Botswana was undertaken in 2014. Ethical clearance to conduct

the study was obtained from the University of South Africa Ethics Committee, HRDC

Botswana and The District Health Management Team for Francistown.

A cohort of 100 HIV positive postnatal women conveniently sampled from two clinics in

Francistown, Botswana. The respondents were identified when coming to attend the 6

weeks postnatal clinic, the Child Welfare Clinic where babies are weighed or in the

injection room where the babies are immunised. The women were offered an

opportunity to participate in the study if they were 21-49 years old. The respondents all

gave consent to participate after being given all the information relating to the study.

A questionnaire was administered to obtain data. The questionnaire was in English and

Setswana.

5.4 CONCLUSION BASED ON THE STUDY OBJECTIVES The ages of the respondents who were included in the study ranged from 21 to 49

years. The majority of the respondents i.e. 30% were aged between 31 to 35%. Eighty-

two percent were single and they lived in rented houses in Francistown. All the women

attended church an indication that church does not hinder the women from seeking

modern health care services.

Bhatia and Cleveland in their study (1995) showed that there is a connection between

education and postnatal attendance. Women who had achieved secondary education

and higher were proven to be independent to demand health care services. In this

study, 775 of the participants had attained secondary education, 125 had completed

primary school, 9% had a University degree and only 25 had never been to school.

The study further indicated that 62% of the participants were unemployed but most of

them had attained secondary education and higher which enhanced them to seek

health care services. Most of the participants had two to three babies. This may

assumable mean that they had been exposed to health care education in ANC with the

42

previous pregnancies. The women had varied periods of knowing their HIV status

ranging from less than one year to more than five years. Generally the biographical data

of the majority of the participants made it possible for them to retain knowledge during

antenatal health education since they had achieved secondary education and had more

than one baby.

The results of this study are in keeping with the findings of (Bhatia & Cleveland 1995) as

ninety-five percent of the respondents received health education during the antenatal

period. All aspects of the antenatal health information were given. The health care

workers who gave health education varied from technical health care cadres such as

health care education assistants and lay counselors to health care professionals who

were nurses, midwives and medical doctors. The study showed that health education

was done by lay counselors followed by midwives, doctors and then other cadres. The

majority i.e. 40% of the women were given health education by lay counselors. The

quality of health education given by these health care cadres varies extensively in

quality because of their different qualifications and knowledge levels.

5.5 BRIEF SUMMARY OF THE STUDY

The study showed that the HIV positive pregnant women were given health education

by different cadres of health i.e. doctors, nurses with no midwifery, midwives, health

assistants and lay counselors. Only 45 out of 159 HIV positive women brought their

babies for PNC. This means that only 28% of six weeks babies and their mothers

received PNC at the appropriate time. There is a possibility that some of the women

moved to other clinics in the country but this cannot be proven in this study since there

is no data linking PNC in the country.

In this study, lay counselors gave health education to most of the HIV positive postnatal

women. This cadre is prepared for HIV counseling and testing and infant feeding

counseling only. It is clear that lay counselors may give health information but at a very

superficial level. One major cause of this challenge is that the midwives are responsible

for consulting and treating antenatal, postnatal and all clients seeking family planning

services. The clinics where data was collected see one hundred to one hundred and

fifty (100-150) patients a day with about a third seeking reproductive health care

services. The midwives complained that they did not have time to give in-depth health

43

information because they have too many clients. According to the National campaign for

safe RN-to-patient staffing ratios ([s.a.]), the recommended nurse patient ratio in skilled

nursing facilities is 1 nurse to 5 patients. Recommendations for practice and further

studies to improve care have been outlined below.

5.5.1 Conclusion

This chapter concludes the study. It has reviewed the purpose of the study, the study

objectives, the research questions and brief summary of the study. The limitations and

recommendations of the study are outlined below.

5.6 LIMITATIONS OF THE STUDY

• Collection of data took time because the sample size was not yet attained. This is

partly because women have to comply with their culture of confinement for at

least three months (Botsetse).

• The quality of health education which was not evaluated in this study could be a

contributing factor since health information was given by differently qualified

health care workers.

• Only two clinics out of 15 were used for data collection.

• The questionnaire was close ended and did not give much room for collection of

qualitative information.

• The antenatal and the postnatal registers are separate. This means that one

cannot trace where the client ended. There is no way of determining whether or

not the HIV positive antenatal woman ever attended PNC.

• In each of the clinics that were involved in the study, there was one midwife

attending to all antenatal, postnatal and family planning clients including babies

who required PCR to be done. It therefore means that the waiting period for

patients was long. This could be one reason why the clients do not wait for health

education.

• The shortage of midwives could also be influencing the fact that clients get health

education from lay counselors.

44

• In Botswana clients are very mobile. There is a possibility that some of the

women who are not appearing in the postnatal register of the clinic where they

had ANC moved to a different location and may be had PNC there.

5.7 RECOMMENDATIONS FOR PRACTICE

• Equip all cadres of health care workers with quality health education skills

through training.

• Increase the number of midwives who consult the antenatal, postnatal and family

planning clients.

• Implement an e-register so that the clients can be followed from antenatal clinic

to the postnatal clinic. Any clients who do not attend PNC may be visited at home

for reinforcement of health education and be encouraged to go to the clinic for

PNC.

• Include other cadres such as health education assistants who already do home

visits to monitor the health of postnatal mothers after delivery.

• Emphasise the importance of PNC during antenatal health education on each of

the client’s follow up days.

• Educate communities on the importance of attending both antenatal and PNC

using recognised community meetings such as the kgotla meetings (meetings

held at the chief’s administrative compound), churches, etc.

• Use social media to educate the general public about the importance of attending

PNC.

• Emphasise the necessity of the PCR test at 6 weeks for the baby.

• Disseminate information to other relevant stakeholders nationally and

internationally.

5.8 RECOMMENDATIONS FOR FURTHER RESEARCH

• A qualitative study need to be carried out to assess the quality of health

information that is given by each cadre of health e.g. doctors, nurses, midwives

etc.

• The perception of PNC by HIV positive mothers.

• The effect of cultural practices on PNC.

45

5.9 CONCLUSION

This chapter concludes the study. It has reviewed the purpose of the study, the study

objectives, the research questions and brief summary of the study, study limitations and

recommendations for practice and further research.

46

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ANNEXURE A UNISA ETHICAL CLEARANCE CERTIFICATE

ANNEXURE B HRDC BOTSWANA APPROVED STUDY PERMIT

ANNEXURE C FRANCISTOWN DHMT PERMISSION TO CONDUCT SUTDY

ANNEXURE D

QUESTIONNAIRE

The effect of antenatal health education on postnatal care among HIV positive women in Francistown city, Botswana.

Instructions: Please answer all the questions as honestly as possible. The information

collected for this study will be collated and analysed. You do not need to identify

yourself. The researcher will uphold anonymity in that there will be no possibility of any

respondent being identified or linked in any way to the research findings in the final

research report. Where required, please indicate your answer with a cross (X) in the

appropriate box or write a response in the space provided.

SECTION 1: DEMOGRAPHIC INFORMATION

1. What is your age? 21-25 years 1 26-30 years 2 31-35 years 3 36-40 years 4 41-49 years 5

2. What is you marital status? Married 1 Divorced 2 Single 3 Widow 4

3. What is your church?

ZCC 1 Traditional 2 Muslim 3 Adventist 4 Catholic 5 Pentecost 6 Other 7

Q4. Education attained University level 1 High school 2 Primary school 3 None 4 Q5. Habitation Own home 1 Flat 2 Other 4 Q6. How many children do you have? One child 1 Two children 2 Three children 3 Four and above 4

7. How many times have you been pregnant? ___________

8. How many live children have you given birth to? ________ Alive/Died_______

9. How old is your baby? ____weeks and days

_____days

10. Employment status (tick only one)

(i)= employed full-time

(ii)=employed part-time

(iii)= self employed

(iv)= unemployed

(v)= other

SECTION II: CLINICAL INFORMATION

11. For how long have you known that you are infected with the HIV? (tick only one)

(i) Less than a year

(ii) One year

(iii) Less than 5 years but more than one year

(iv) Five years

(v) Above five years

12. Who spoke to you about health information at the clinic during this last pregnancy? (tick only one)

(i)Midwife

(ii)Nurse who is not a midwife

(iii) Doctor

(iv) Heath Education Assistant

(v) Lay Counselor

(vi) Other health care worker. Specify______________________

(vii) I do not know the cadre of the health care worker

13. Did the health care worker talk about? (tick Yes/ No or NA)

(Probe for answers if respondent is hesitant)

Number Antenatal Health Education points Yes No N/A 13.1 Growth and development of your baby 13.2 Diet appropriate for a pregnant woman 13.3 Importance of personal hygiene 13.4 Smoking during pregnancy 13.5 Drinking alcohol or using other illicit drugs 13.6 Sexual intercourse in pregnancy 13.7 Vaccination for both mother and baby 13.8 Infections during pregnancy 13.9 Bleeding during pregnancy 13.10 HIV in pregnancy 13.11 Information on Mother to Child transmission of HIV 13.12 Diabetes Mellitus in pregnancy 13.13 Taking medication in pregnancy 13.14 Vitamins and supplements for pregnant women 13.15 Delivery options (i) normal vaginal delivery (ii) caesarian

section

13.16 Environmental and workplace exposures if applicable 13.17 Hereditary diseases 13.18 Natural disasters 13.19 Available medical, psychological and social services for

HIV positive pregnant women

13.20 Infant feeding options. 13.21 Importance of attending postnatal care 13.22 Blood tests necessary for mother after delivery 13.23 Six weeks HIV testing for your baby 13.24 Importance of taking ARV treatment

14. You visited the clinic or had a health care visit you at home; (tick one only)

(i) Before 6 days after delivery

(ii) At 6 days after delivery

(iii) 6 weeks after delivery

(iv) I never visited the clinic nor had a health care worker visit me at home

(v) Other – Specify: …………………………………………………………………………….

THANK YOU FOR YOUR TIME AND COPERATION!

ANNEXURE E

The effect of Antenatal Health Education on postnatal care among HIV positive women in Francistown, Botswana

Informed consent

My name is Stembile Matambo. I am a nurse studying Master of Arts in Nursing Sciences at the University of South Africa (UNISA). I am here to ask you questions on the health information that you received at the clinic during pregnancy. I will also ask you questions about yourself and the person(s) who provided you with the health information.

I am going to be writing on this form as you give your answers to help me put answers together for all women who will be involved in this study. The form does not have your name to ensure that no one knows who gave me this information. The information will be kept private.

The benefit of this study is that it will help the health care system to develop the information given during pregnancy so that it includes all the necessary information for pregnant women who are HIV positive.

The risk is that the meeting may take more than 15-20 minutes which was in the plan for the interview. You also may be upset as you recall events that happened in the past. If this happens to you, I will give you time to reflect and to talk more about how you feel. I may also refer you to a health care worker in this clinic who will help counsel you.

Participation is voluntary. You may refuse to be included in this study. You may choose to discontinue the interview at any time. Discontinuation will not result in refusal for your treatment or any care for you and your family in this clinic or any other health facility.

You will not receive money or reward of any kind if you agree to participate in this study.

Do you have any questions for me?

If you have questions after you leave the clinic, you can call me on 71601478 or contact the nurse in charge at the clinic on telephone number-------------------.

In the next part, when it says “I”, it is referring to you.

Subject statement:

I have read or the above consent regarding my participation in the study was read to me. I have been given a chance to ask questions that I may have and my questions have been answered to my satisfaction. I understand that the information I give will be kept private. I also understand that participation is voluntary and that I may withdraw from this study at any time. My withdrawal from this study or refusal to participate will in no way affect my or my family’s medical care from this clinic or any other clinic.

I agree to participate in this study as a volunteer.

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Signature of volunteer Date

Documents

THE EFFECTS OF ANTENATAL HEALTH EDUCATION ON POSTNATAL